Original

Juan J. Lpez-Ibor 1
Blanca Reneses 1

Clinical management and

management of processes in the
mental health setting
1

Instituto de Psiquiatra, Hospital Clnico San Carlos

Department of Psychiatry
School of Medicine
Universidad Complutense de Madrid
Instituto de Investigacin Sanitaria del
Hospital Clnico San Carlos (IdISSC)

Centro de Investigacin en Red CIBERSAM

Spain

The emergence of new management models into the

health care setting is not the consequence of economic or
financial needs but of a profound transformation in the
supplying of the services (doctors and health care workers),
citizens (patients) and the state administration.

better expert on the disease, should inform the patient

about all of its characteristics, therapeutic resources and
implications so that the patient can make an informationbased decision. The informed consent, thus, is the axis in this
doctor-patient relationship.

In recent years, there have been radical changes in the

nature of the patient-doctor relation which entail new
ethical demands for the professionals. The changes are a
consequence, on the one hand, of the triumph of the ideas
of the French Revolution and the secularization and
Democratization of the modern societies. On the other
hand, they are determined by the economic forces which,
simultaneously, have made it possible for extraordinary
progress to be made in recent decades and the
universalization of care. They have introduced a third
character into the doctor-patient relation. This third
character, funding, is precisely that which has made it
possible for the patient to go to the doctor. It takes on the
form of national health services or insurance companies.
What this means is that although in the past, the doctors
art and science were sufficient to practice his profession
with the few citizens who had access to him, the patients
are currently increasingly better informed and more experts
and responsible. The professionals are more capable and
better trained, the medical technology is more complex
and efficient. We are now within a totally new scenario
and line of argument.

The fact that health has been recognized as a right, the

statement that premature death or discapacity because of
the disease is not only a personal problem but one that is a
social burden (this being which is measured by the DALYs),
converts universal coverage into an unavoidable goal.
Consequently, the funding of medicine and health care
economy is currently no longer a personal problem but also
a social one. Until recently, only those who could pay for it
went to the doctor, but nowadays the state is required to
manage what is the right of the citizens, in the case of Spain
supported by the existing Constitution. Limited resources,
individual demands and social responsibilities can only be
compatible with adequate management of resources, this
being so important that it is possible to speak about ethics
of management, which we prefer to call ethics of fairness,
based on a distributive justice that is provided in accordance
with the needs of each individual.

The ethics of traditional medicine is that of welfare. The

traditional relationship of the doctor was based on achieving
patient compliance, based on the fact that the doctor did
what was best in benefit of the patient, because it was the
doctor who had the knowledge to do so and to make the
best decisions.
In 1972, the American Society of Hospitals published
the Patients Bill of Rights, which considered the adult
individual as autonomous and free and therefore capable of
making their own decisions. That is how the ethics of
autonomy was born, and in accordance with this, the patient
decided what was best for him/her and the doctor, being a

The Challenge of Mental Diseases

Among other things, mental diseases are characterized
by their complex origin, relatively low mortality and high
chronicity, their high prevalence and for being very
incapacitating and stigmatizing. All of this makes it necessary
for them to have a wide range of medical and psychological
as well as rehabilitation resources.
Biological, psychological, and social factors intervene in
the complicity of its origin. Some are genetic ones, which
condition vulnerability, and others are the consequence of
stressant environmental factors that intervene in the
precipitation and maintenance of the chronicity and that
can act as epigenetic agents. Furthermore, as in many other
diseases, once they are initiated, defensive or compensation
mechanisms appear. These mechanisms sometimes become

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Juan J. Lpez-Ibor, et al.

Clinical management and management of processes in the mental health setting

self-destructive and therefore become objectives of

therapeutic intervention. There is no doubt that both pain
and inflammation have great adaptive value. However, it is
also true that in the clinical practice, they must be combated
when their function is no longer useful and meaningful. In
fact, analgesics and anti-inflammatory drugs are among the
most prescribed drug groups. The same occurs with the
general adaptation syndrome and the adaptation of the
diseases described by Selye1 and the great use of
corticosteroids and analogue drugs.
Something similar occurs on the psychological level.
Anxiety, essential for individual survival, can become a
serious symptom that must be treated with anxiolytics and
controlled with psychotherapy techniques. Anxiety and
stress are two sides of the same coin. Bakan2 already
described the parallelism between the ideas of Selye and of
Freud3 years ago and as Freud, he had to complete his
theories on the role of libido in the origin of neurosis with
those of the role of death drive that became clear when
studying the obsessive phenomena and recurrent dreams
after a traumatic event. This phenomenon is so destructive
when it is dissociated from libidinal drives that Stekel4 called
it Thanatos.
We also found the same on the social plane. The
psychiatric establishments which, at least since the work of
father Jofr,5 arose to protect the patients from the abuses
and harm infringed by persons, ended up becoming total
institutions,6 that is, they controlled all aspects of the life of
the inpatients in which the patient lost their individuality
and thus the possibility of recovery. In fact, something that
is not generally lacking in the asylums is a cemetery in which
the person in the asylum could rest in his/her final days.
What has the response of psychiatry been to these
challenges? Or more specifically, that of psychiatry, medicine
and society in general, as the responsibilities are shared. The
response was the traditional one , as we have already seen,
nosocomial, which was abolished, at least officially, in the
1970s with the processes of deinstitutionalization7 and
psychiatry reform.8 However, the advance supposed by such
a radical change was soon blemished by the emergence of
conflicting positions, arising from and nurtured from the old
anthropological roots and with combative spirit, meriting
better causes, which gave rise to different psychiatries:
biological, psychodynamics, behavioral, systemic or social.
The underlying fight for power is revealed if we take notice
that some of these psychiatries are linked to care devices
or forms: of general hospital, community, referrals, etc.
None of the pseudo-disciplines have been able to respond to
the needs of the patients and even less so to those of
research. This should be recognized. Allow us to give some
examples.
The medical model, or better said, the already expired
medical model, links mental diseases to an organ, this being
2

of course, the brain. However the failure of neuropathology

over many decades was shocking. Thus, it could be said that
endogenous psychoses are the Delphic Oracle of psychiatry9
or
that
schizophrenia
is
the
cemetery
of
neuropathology.10
There is no doubt that which Freudian psychoanalysis
has provided to the knowledge of the human being and its
illness is of core importance. However, its contributions as
therapy in comparison are scarce. Thus, the great critic of
psychoanalysis, Thomas Szasz, has been able to state that
neurosis is a religion and psychoanalysis is a cult11 and that
psychoanalytic treatment, because of its lack of specificity,
is outside of the channels of medicine. It is, he states, as if a
radiologist would obtain the same kind of plaque for all the
patients regardless of the indications.12
It must be stressed that from extreme postures of
psychoanalysis, from the behavioral or systemic schools of
thought and from the most anti-psychiatric trends, mental
illness is a myth. This leaves suffering mental disorders out
of reach of all coverage regarding their health care needs. As
always, every revolution leaves a trail of the sacrificed, in
this case those who suffer mental diseases. It also must be
said that the result of this will be that many professionals
will be unemployed.
We previously mentioned that the traditional medical
model is outdated and that the notion of morbid entities has
been replaced by others that revolve around the model of
vulnerability and stress.13, 14 No one has been more critical of
the Kraepelinian models then Kraepelin himself. His own
words are:15
The method applied up to now to define the forms of
diseases, considering the cause, manifestations, course
and outcome, as well as postmortem findings have been
exhausted and are no longer satisfactory, so that new
pathways should be investigated.
In almost one century, the situation has not changed.
The testimony of Hyman,16 who mimicked the text of
Kraepelin word by word, is sufficient:
Contrary to the optimistic expectations, the strategies
for diagnostic validity based on clinical descriptions,
laboratory studies, and natural history of the disease
and familial aggregation have not contributed to forge
a nosology based on valid nosological entities.
The Kraepelin model had another problem. For him,
mental diseases are characterized by their final stage, not
by their course, as is generally stated, which in the case of
schizophrenia, was total destruction of the psychic life
(Zerstrung), a notion derived from the concept of
endogeneity of Mbius17 and that of degeneration of
Morel.18 This last concept is contrary to Darwins theory of

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Juan J. Lpez-Ibor, et al.

Clinical management and management of processes in the mental health setting

evolution19 (published five years later!). This stresses the

enormous severity of some diseases that destroy the most
specifically human, acquired over millions of years of
evolution.
Kraepelin himself indicated new roadways in the
mentioned work. These included a proposal of functional
classification, not very different from the current approach
of Wakefield20 and the need to distinguish between
predisposing factors and deteriorating ones, something
which needed to be recovered. It must be stressed that this
functional approach revolves around the concept of harmful
dysfunction, which clearly invades two essential aspects in
nature of mental diseases: the world of values and the social
aspects.21

Current management of psychiatric

services

Table 1

Health Care costs (% of the GNP)

and Life Expectancy (years, countries
selected) in 2009 (Data from the
OECD)2727

Country

Health Care Cost1

Life Expectancy2

USA

17.4

78.2

Sweden

10.5

81.5

France

11.8

81.0

Germany

11.6

80.3

The United Kingdom

9.8

80.4

Spain

9.5

81.8

Japan

8.5

83.0

Luxembourg

6.8

80.7

http://www.oecd.org/dataoecd/26/24/48406859.pdf
http://www.oecd-ilibrary.org/social-issues-migration-health/lifeexpectancy-at-birth-total-population_20758480-table8
1
2

Behind all this, there is a human being in need who is

the axis of the medical action. This entails the need to
manage complex situations and the so-called managed
care,22 that deals with the coordination of resources, of the
consensus on interventions and outcomes, teaching
communication and continuity of cares. Managed care
requires the incorporation of a different dimension that
broadens the setting of action of the administrators and
professionals.23
This is how Patient Focused Care24 arose in which care is
the final objective. It tries to provide the patient more
adequate and satisfactory services, to assure continuity of
cares over the course of the disease, to assure excellent
quality, which responds to their needs and expectations. It
also attempts to facilitate the daily work, reducing the
variability and introducing clinical management strategies,
all at an optimal cost to assure sustainability and increase
the value of the service provided.
The financial aspect is important, as we read and hear
daily. However, that referring to the values of the current
society among those who have the right to health and to
receive health care is no less important. The 2010 World
Health Report focuses precisely on this. It is entitled: Health
systems financing: the path to universal coverage.25 One of
its sections is on Promoting efficiency and eliminating
waste. In this, strategies are mentioned to ensure that the
resources are used effectively, to get the most out of
technologies and health services, to improve hospital
efficiency, to get care the first time, by reducing medical
errors, to eliminate waste and corruption and to critically
assess what services are necessary. This report has made a
worrisome but hopeful mention, since it is a challenge and
an opportunity: about 20-40% of the resources spend on
health are wasted.

In 2010, the cost of brain disorders (mental disorders

plus neurological disease) in Europe was 798 billion , the
direct costs accounting for 60% (37% direct health costs
and 23% non-medical costs) and 40% are indirect costs due
to loss of productivity of the patients.26 The problem is that
lack of resources for health care is inevitable, since health
per se requires investments in other areas such as education,
protection of the environment and of the family. On the
other hand, there is no correlation between health cost
(measured as % of the Gross Domestic Product or GDP) and
general health27, 28 (considering life expectancy as index)
(Table 1).
We have already stated that the financial aspects are
important, but that they are not the only ones. Medical
management has to include management of resources
(economic and human), management of knowledge and of
values.29, 30 The former is measured in activity and costs, the
second according to the scientific evidence. The third
revolves about the needs felt, the expectations, and has a
high affective component since it moves the foundations
of the existence itself of the patient (Figure 1). In each one
of them, the weight of the medical decisions is different
(Table 2).
Health care management basically consists in having
and organizing the elements and resources of a health care
system to achieve the best possible results in the health state
and quality of life of the patients and users.
Medical care given in any health care system is strongly
determined by the decisions made by the doctors. This has a
repercussion on the quality of service provided to the

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Table 2

Clinical management and management of processes in the mental health setting

The weight of the clinical decisions

Type of Ethics

Responsible person

Traditional (of charity)

The physician

Of Autonomy

The patient

Of equity (of management)

Health Care Administration

The physician
The patient

patient. However, as the doctors obtain an increasing greater

influence in the allotment of health care resources, their
influence grows in the administration decisions.
Consequently, they demand greater autonomy and
responsibility in health care policies. This results in a new
management frame that permits them to development their
projects and aspirations from the perspective of professional
ethics and commitment with the values of public service.
However, not all physicians are the same and in keeping
with that stated above, it is possible that the greatest
disparity is found between psychiatrists and even more
between mental health care professionals. It should be
remembered that the rule in many community resources has
been, and perhaps continues to be, allotment of professionals
according to their arrival: first for the psychiatrist, second
for the psychologist, third for occupational therapist, and
successively. This is what has been called unwarranted
variation of John Wennberg31 in the providing of health care
services. This type of analysis deals with the differences that
cannot be explained by a disease, medical need or scientific
evidence. The causes of the variability are complex, but in
general are due to not correctly applying that which research
dictates, to decisions of a patient who is not sufficiently
informed or of a care structure not based on real needs and
on evidences on whether they are adequate or not.
Therefore, the fight against unjustified variation has
been made on three fronts: 1) scientific, that is, in accordance
with evidence-based medicine or on facts; 2) the personal
that concerns, above all, the patient and the patient setting
in accordance with value-based medicine and 3) that of
management, in accordance with the principles of Patient
Focused Care and with the development of consensus-based
care strategies between the different agents: state
administration, professionals, user associations and civil
societies in general.
The needs for multidisciplinary and teamwork,
participation of a large amount of resources involved, and
coordination between services and the fact that neither
patients nor diseases understand specialties make the
4

management of the process an essential requirement for

good health care organization.
Traditional clinical services have some characteristics
that do not allow them to handle the needs of the current
clinical management. They have a pyramidal structure. Their
organization chart is rigid. Initiative and control, when they
exist, go from above to below and their culture is that of
submitting to a unilateral model. The consequence of all of
this is that many times the goal is not the patient but rather
that of serving the model, to protect and expand it.
Emphasis on the patient and not on the system and also
not on the disease itself has led us to design a management
of processes based on statistics, since the needs, goals,
interventions, and professionals and resources involved are
different in different evolutionary moments.
Methodology of management of processes is based on
the systemic analysis of the sequence of the activities
which include a care process and its graphic representation.
To do this, it is necessary to define all of the activities and
to analyze their quality characteristics. It means defining
what is going to be done to satisfy the expectations and
needs of the patients. It is very important to include
indicators to measure and analyze systemically the results
obtained and their tendency over time and to be able to
establish new priorities.32 In the Institute of Psychiatry and
Mental Health, we have used the European Foundation
Quality Management (EFQM) model as the scaffolding to
structure the processes, with the added intention of
extending the culture of quality and its measurement to all
of the members.
From the point of view of management, a process is an
action setting in which some persons, based on their
knowledge and resources, carry out a series of interrelated
activities, transforming an entry into an exit that provides
an added value or utility for its recipient. One process may
be made up of several subprocesses and different persons
carry them out in accordance with a series of activities
defined by a set of rules and instructions, called procedures.
A process can be a disease (bipolar disorder), a
combination of them defined by administrative criteria
(GRD- Psychosis) or by high comorbidity or analogue
problems (stress -anxiety -depression) or caravans
(emergencies). Management of processes are often carried
out spontaneously and thoughtlessness in many areas of the
daily life and above all in teaching and management of
research projects. It is difficult for medicine to incorporate
them because it is feared that this would mean a change of
power forces in the area of the professionals who are dealt
with as doctors without having obtained a PhD or matres in
France, a degree which in Spain is reserved for the bullfighters
and some celebrities in other arts.

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Clinical management and management of processes in the mental health setting

A process consists in an entry, a typology of patients

with their expectations and needs, and an exit, satisfaction,
at least partially, of them with the units resources. These
resources, once more, have a different nature (human,
materials, internal structure, knowledge, tradition, etc.) and
differ from one care unit to another.
It is important to indicate that the responsibilities within
a process may be outside of the site of the persons involved
in the organization chart of a service because the fact of
having reached it does not suppose they are capable of
carrying out the different procedures included in it.
Management of processes means creativity beginning from
the top going down, which is fluid and constantly evolving.
Thus, management of processes cannot be established by an
order or administrative recommendation nor can it be
imported from other care centers.
Management of processes go beyond this since, due to
their orientation to needs and expectations of the patients,
this management is an instrument for the improvement of
the care units, for the definition of priority, which necessarily
will be a consequence of these needs and expectations of
the population to be attended to. Definitively, they are, from
our point of view, the best tool for the progressive
redefinition of the view, mission and values of the
organization.
Implementation of a management of processes includes
a series of requirements:
1. Its development must be autochtone and not imposed
or imported.
2. It requires an organizational structure of the modern
care unit, which is not greatly hierarchized, in whose
culture there is predominance of transparency,
democratic management, team work, differentiation
and professional qualification, and social commitment.
3. It must be progressively implemented due to the needs
of its development and its implications in the structure
of the care unit. It also means a profound change in the
working habits, which must be assumed as necessary
and enriching.
4. The processes to be introduced should be chosen by
consensus for strategic reasons. Sometimes it is
recommendable to choose a simple one to have the
opportunity to learn. Other times, it is necessary to face
a demand which, due to its dimensions, complexity,
diversity of professionals, units and services involved or
social relevance, is required. The proposal by the
spontaneous leaders is a determining criterion as well as
evaluating beforehand possible resistances to change to
be able to solve them. Thus, a process map with their
corresponding subprocesses is developed.
Starting from here, the development of each process
requires:
1. The naming of a work group with representation of the

experts in the activities proposed. This group can vary

over time in size and composition.
2. The group will define a methodology of meetings, tasks
and periods.
3. The writing of the Process Card. This card should include
its global definition, its recipients and objectives,
components of the process (activities, characteristics of
their quality and professionals involved in each one of
them), chart of the processes and the possible
subprocesses and indicators for monitoring the results.
4. Personnel who should be assigned and percentage of
their work day dedicated to the process.
5. Reference documentation: own documentation, external
documentation and applicable legislation.
6. Limits of the process: start and end of process.
7. Leader of the process (in some settings, it is called
owner): the leader assures compliance of the process,
taking responsibility for its management and
improvement.
8. Development: Sequence of activities that make up the
process. It is generally represented by table, indicating
the activities, quality characteristics of each one of
them and the responsible persons.
9. Graphic representation of the process in form of flow
charts that indicate the sequence of the activities and
the relation between them.
10. Indicators: measurement tool and instruments that
make it possible to evaluate and control the process.
They should be measurable, understandable and
controllable.
11. Registries: they collect the evidence of the
performance.
12. Collection of measures necessary to carry out the
continuing improvement of the processes.
The clinical management supposes significant
decentralizing of the administration, responsibility and risks.
Each professional contributes as an important protagonist
towards the success of his/her small or large parcel, whatever
profession the person has. In this work scheme, the
multidisciplinary professional teams and collaboration
programs between care levels acquire maximum interest as
they are core to the organization of the care. The care is
organized according to the needs of the patient or a profile
of patients with similar needs.
The clinical processes are defined as a set of medical
care activities and cares that are required by a specific type
of patients who have common characteristics in regards to
their diagnosis and therapeutic needs. Management of the
processes is thus a central tool in the clinical management
and quality management.33
Emphases on Patient Focused Care and our own
management model, which is an Institute of Clinical
Management, led us to adapt Management by Processes as a

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Clinical management and management of processes in the mental health setting

priority objective in our organization (the Institute of

Psychiatry of the Hospital Clnico San Carlos of Madrid).

facilitating the study of the neurobiological markers of the

state and traits according to the diseases.36

The first Clinical Process we have developed is Depressive

Disorders and Anxiety. This process is characterized by
including both specialized resources of the Hospital and of
the outpatient psychiatric services as well as those of Primary
Care of its area of influence.

Staging of the classical medical diseases is based on the

anatomical alteration and the impact of the disease on the
body. On the contrary, in psychiatry, the factor of course
and response to treatment is introduced as an element for
the definition of the stage. Mcgorry and his group37 were
pioneers in defining a heuristic model of clinical staging for
psychiatric diseases, considering that most of the disorders
are susceptible to inclusion in a model of this type. As
proposed by OD Howes et al.,38 we are currently only able to
partially predict results according to certain clinical
characteristics, but we have a limited understanding of the
physiopathology.

The elevated prevalence of depressive and anxiety

disorders and the fact that an elevated proportion of them
receive treatment in Primary Care served as an argument to
make this the first clinical process we designed. In other
articles of this supplement, the characteristics of this
collaboration program with Primary Care, the details of each
clinical subprocesses, the steps for their development and
implementation and the system of indicators for their
evaluation are shown.

Clinical staging and Management by

processes in psychiatry
Clinical staging has a relevant role in several branches
of medicine and can currently be considered a pending
subject in the setting of diagnostic classifications in
psychiatry.34 Its potential utility is that of contributing to
the establishment of the diagnosis of the disease and its
prognosis with greater accuracy, orienting the clinician and
the therapeutic strategies with greater possibility of success
in each stage. The primary objective, such as that defined by
PD Mcgorry,35 is to define the extension or progression of
the disease in a time cut off period, differentiating the
clinical phenomenon from the initial or intermediate phases
of those that are characteristic of its progression and
chronicity.
From our viewpoint, this model would contribute
additional advantages both in the clinical setting as well as
in that of the evaluation of results and of the investigation.
From the clinical point of view, the staging model would
permit greater accuracy in the prediction of the evolution
(once we can identify clinical and neurobiological markers in
each stage). It makes it possible to better identify the current
clinical situation of a very specific individual on the
continuum of the disease and it facilitates the choice of
specific therapeutic interventions using scientific evidence
according to the clinical stage, minimizing the risks. From
the point of view of the evaluation of results, it facilitates
the evaluation of effectiveness of the interventions oriented
towards prevention (the therapeutic objective would be to
achieve regression in the stages, remission, or no
progression).
Within the area of research, staging may contribute to
specifying and giving order to the clinical situations better,
6

In the area of depressive disorders and anxiety, Hetrick39

and the same group of Mcgorry have proposed a clinical
staging model that we have adopted with some changes and
that is described in greater detail in the article entitled:
Clinical Management for Depressive Disorders in
Departments of Psychiatry published in this supplement.
The interest in adopting this tentative model is based on
its good adaptation to the clinical use, its simplicity and ease
of understanding by the physician and above all because of
its potential capacity to improve the diagnoses and clinically
typify the patients better.
The subprocesses and therapeutic decision algorithms
that serve as support to the clinicians in the subprocesses of
the psychiatric departments have been made on the mention
staging model, also including the applicability diagnostic
classifications. In other words, each line of therapeutic
decision is defined based on a clinical stage or sub stage.
In the Primary Care services, the clinical staging model
in the Process that we are dealing with has not been included,
even though it is exactly in this care setting where early
detection and action on the first stages of the disease are
especially important. The logical limitation of our resources
because we are within the frame of the National Health
System has not allowed us at present to go beyond this,
although it is an objective in the near future.

Conclusions
The tools provided by Clinical Management and
especially by Management by processes are especially useful
for the direction of the psychiatric departments. The principal
reasons are because of the characteristics per se of mental
diseases (chronicity and variable need of multiple resources
and professionals), by the characteristics of the Psychiatric
Departments (usually formed by networks of different units)
and by the demand of society (medicine based on scientific
evidence, focused on the patient, that also responds to social
and economic values).

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Juan J. Lpez-Ibor, et al.

Clinical management and management of processes in the mental health setting

In this supplement, the result of the design of a

collaborative clinical process with Primary Care for the care
of Depressive Disorders and Anxiety in the Hospital Clnico
San Carlos and the Care Administration Center of Madrid is
shown.
Our objective is to show that the design of a clinical
process in psychiatry is possible, enriching it with the
involvement of the Primary Care Services. Although each
process should be developed according to the characteristics
of each network of services, this supplement aims to explain
the basic elements of the method to carry out a clinical
process, showing the result of our own experience.
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